For this assignment, you will present a patient case presentation to your peers about a patient you have cared for during your clinical hours. The patient you choose should have multiple co-morbidities and/or a complex diagnosis.
Your presentation should include the following:
Patient demographics (5 pts): initials, age, gender, date of admission, length of hospital stay
Admitting diagnosis (10 pts)
This should also include the pathophysiology of the admitting diagnosis
Consults (2 pts)
Past medical history (2 pts)
Past surgical history (2 pts)
Past psychiatric history (2 pts)
History of present illness (the story of what brought them to the hospital) (5 pts)
Provider orders (5 pts)
Assessment findings (10 pts)
Compare and contrast expected assessment findings for admission diagnosis vs. what the patient currently has. Be sure to cite the source for the expected assessment findings.
Labs and diagnostics (10 pts)
Compare and contrast expected labs and diagnostics for admission diagnosis vs. what the patient currently has. Be sure to cite the source for the expected assessment findings. Also include other labs and diagnostics obtained for the patient.
Medications (include PRNs that the patient received) (10 pts)
Please note if the medication given is in the normal dose range.
Hospital course (this should be a summary of what the patient experienced during their hospital stay) (12 pts)
Discharge plan (20 pts)
This should include the current discharge plan. Also identify aids and barriers to the discharge plan: what will help the patient be successful and what might get in the way? What resources will be the patient need at discharge? For example, home health. What referrals will the patient need at discharge? Does the patient have any psychosocial needs at discharge? Be sure to cite your sources in this section.
Reference page and APA format with appropriate journal articles is expected. (5 pts)
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